Dear Dr. Altough I am not an expert writing in English I will try to make me undertand.

I am on five year of treatment of anti retroviral, currently on 3TC + D4T + Efavirenz. Since I started on this schedule I have been experiencing fat wasting. I am concern that D4t is a problem. My question is: Can I back to my prior schedule on Lamivudina and Efavirenz where I did'nt experience any fat wasting? My doctor changed my first schedule due to intolerance to that medication, or there are any better way to resolve my problem. I live in Nicaragua but i prefer to consult with you this.

Regards

Response from Dr. Pierone

Hello, and thanks for posting. Your concern that d4T (Zerit) is the problem is likely correct since this agent has been linked to an increased risk of lipoatrophy. The part of your post that I don't understand is what the intolerance was to the regimen of lamivudine and efavirenz, since you are still on this regimen now (lamivudine is 3TC).

Nevertheless, if tenofovir (Viread) is available in Nicaragua, then simply changing the d4T to Viread would make the most sense. A number of studies have shown that this switch strategy will help reverse lipoatrophy.

An alternative tactic would be to simply stop the d4T and continue lamivudine (3TC, Epivir) and efavirenz (Sustiva). This regimen would probably be strong enough to control viral replication, but there would be increased risk of virologic failure and development of viral resistance. There was a switch study from France named "COOL" that looked at condensing a 3 drug Sustiva-based regimen to a 2 drug cocktail of Sustiva + Viread only. After one year, 15 percent more patients on the 2 drug regimen developed virologic failure compared with those on the 3 drug combination. There are no studies of Sustiva + Epivir only, but there are anecdotal cases where this regimen has been found to be effective.

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